Cardiology clinic

Cardiology Clinic Referral Guidelines

Schedule of clinics

In Martinez, there are two cardiology clinics:

Every Tuesday staffed by Dr. Mahar from CCRM|C

Every fourth Tuesday of the month staffed by Dr. Mahar and by Dr. Arnold (East Bay Cardiology), with Internal Medicine staff and residents

In Richmond, Cardiology Clinic is every first and 3rd Wednesday and is staffed by East Bay Cardiology (Dr. Weiland)

In Pittsburgh, there is a weekly Thursday clinic staffed by Dr. Mahar from CCRMC

Insurance status

MediCal is not accepted at John Muir Concord, formerly Mt. Diablo. As a result, all MediCal patients referred to cardiology will either be seen in

Martinez or in Richmond Cardiology Clinic. If a procedure is needed, they will then be sent to Doctors Hospital.

Non-MediCal patients will be sentfor procedures in accordance to where they live (West County patients will go to Doctors Hospital/East Bay Cardiology

group and Central or East County patients will go to John Muir Concord/Contra Costa Cardiology group)

Referral Guidelines

Appointments are very limited at our cardiology clinics, and therefore they cannot be used as ongoing care clinics.



To maximize efficient use of these few appointments, please use the following guidelines.

All patients need a primary care provider who makes a referral, asks specific questions of the consultant, and can accept the patient back after

consults, catheterization, etc.

Routine patients who are revascularized for angina do not need routine follow-up in cardiology or internal medicine, but the following patients are

higher risk and should probably be referred:

Left main stenting or suboptimal PCI results (may need repeat procedure)

Decreased LV function: refer to Medicine or any of the STRONG CHF providers

Diabetes with multiple stenting procedures or CABG: refer to Medicine (lower threshold to do repeat cardiac ischemic evaluation)

Keep in mind that all patients with coronary disease should have secondary prevention:

Aspirin

Statin to achieve LDL cholesterol near 70

ACE inhibitor for poor LV function

Beta-blocker for angina, HTN, post-MI, or decreased LV function

Other risk factor reduction (smoking cessation, diabetes control, etc)

After stenting, patients should be on both aspirin and clopidogrel (Plavix), unless bleeding contraindications. The duration of Plavix therapy is:

All acute coronary syndrome patients (unstable angina, non-STEMI or STEMI): 1 year

Bare metal stent: minimum 1 month (if surgery or high bleeding risk), preferably 6 months

Drug-eluting stent: minimum 1 year, sometimes longer (complex stenting, alot of risk factors for thrombosis)

Not all family practice providers are comfortable following patients with CHF or other stabilized, significant heart disease. That is fine. However,

rather than refer such patients to cardiology clinic for ongoing primary care or follow-up, they should refer such patients to other family practice

providers who are comfortable, to the trained STRONG CHF providers, or to internal medicine/adult medicine practitioners

Prior to referral, all patients need an ECG. In addition:

CHF or heart murmur referrals also need an ECHO and CXR

Angina or atypical chest pain referrals also need a stress test

Palpitation referrals also need a Holter (can be 24, 48 or 72 hours) or a month-long event monitor for infrequent palpitations

Prior to referral (unless urgent), outside records (e.g. cath reports, prior cardiology consults) should be obtained and sent to the clinic where

patient is to be seen.

Keep in mind that any patient who had a recent catheterization, stent or CABG also had a cardiology consult

Reviewing these records or speaking with that cardiologist often eliminates the need for another consult

For palpitations

In patients without structural heart disease (ECG, CXR and exam normal), most palpitations are not due to arrhythmia

When PVCs cause palpitations in patients with normal hearts, they are called "benign" PVCs, and no treatment is necessary (except reassurance

and avoidance of stimulants)

Unless a patient has structural heart disease and there is a concern for symptomatic V. tach, the case should first be discussed with a medicine

attending to see if referral is needed.

Pacemaker patients should be referred to Pacemaker Clinic, through the cardiopulmonary department at 370-5585. Pacemakers should be checked a minimum

of every 6 months.

Examples of common incomplete or inappropriate referrals

1. "Chest pain, please evaluate", but no ECG or stress test is done.

2. "Recent CABG, needs cardiology follow-up"

3. "Stent last year, please make routine recommendations" (see above)

4. "Heart murmur" (with no description of murmur or symptoms and no echo done).

5. Pt seen one time by fill-in MD in FPC who will not see pt. back and refers to cardiology with no questions, asking for ongoing care of "heart

disease". Our cardiology system cannot support these types of referrals.



(last updated by Denis Mahar, December 2011)